††††††††††† Insulin
dependent diabetes mellitus, also known as type 1 diabetes, causes severe
neurological and cardiovascular disorders.†
Insulin plays a crucial role in maintaining glucose levels within the
circulatory system.† Glucose levels that
are unregulated in the DM 1 patient may lead to possible life threatening
situations.† These situations can be
either acute, such as diabetic (hyperglycemic) coma; or chronic, such as distal
neuropathy and atherosclerosis.† The
proper education of exercise, nutrition, and monitoring of blood glucose levels
is crucial.† Physical therapists should
necessitate this education for our patients that their acts are imperative to a
healthy life.†

Diabetes is a condition that can be
managed to an extent.† Management will
reduce the health care costs and promote longevity to our patientís lives.† The role of our profession in patient education
is important.† Exercise and nutrition
has shown to reduce the amounts of insulin required for our bodies.1† As physical therapists, we must promote the
benefits of exercise and nutrition to diabetes patients.†

The relationship between exercise,
blood glucose, and insulin will be broken down into the following categories:
exercise and itís effects on blood glucose, exercise and itís effects on
insulin, and insulin and itís effects on blood glucose.† These categories will demonstrate the
effects of pharmacologic interventions and non-pharmacologic interventions on
diabetes.† The best possible solution
for control of blood glucose levels will be explored.† This will demonstrate the importance of insulin injections vs.
nutrition/exercise and their effects on blood glucose levels.† The final section of this mini-paper will
discuss the appropriate regime to be used for a patient with Insulin Dependent
Diabetes Mellitus (IDDM).

Exercise and itís Effects on Blood Glucose

Exercise demonstrates positive
effects on both the cardiovascular and pulmonary systems.† These systems are directly affected by
IDDM.† By utilizing exercise as a
treatment, the therapist can decrease the effects of diabetes.† A brief overview of the effects of IDDM on
the cardiovascular and neurological systems is reviewed below.† This is followed by exercise and itís effects
on glucose.

IDDM has various effects on the
bodyís systems.† In the cardiovascular
system, IDDM causes a decreasing diameter inside our arteries, which is
secondary to the increased deposits of†
ďfatty plaques.Ē2 †This decrease in arterial diameter causes an increased cardiac
output in order to maintain oxygenation of the bodyís tissues. When cardiac
output is increased, the respiration rate is also increased to adequately
oxygenate the blood.† The pulmonary system
is then stressed to match the cardiac output.†

This cycle is caused primarily by
the increased blood-glucose levels found in IDDM patients.† An increase of glucose in the bodyís
vascular system, and the inability to absorb it, leads to increased amounts of
sorbitol to be deposited around nerve cells.2† †IDDM patientís with
diabetic neuropathy are at a higher risk to injure their distal
extremities.† With decreased sensation
from diabetic neuropathy, IDDM patients are at higher risk of developing
integumentary injuries.

†The cycle becomes worse with the possible effects on the distal
vascular system.† With decreased
arterial size, secondary to fatty deposits, the bodyís capillary system also
begins to restrict blood flow.† IDDM
then takes a major effect on the healing process.† Wound care is challenged secondary to decreased capillary
sufficiency.† Minor scrapes or injuries
to the distal extremities can require months of wound care and
rehabilitation.† The immune system is
challenged by decreased phagocytosis of leukocytes.2† This challenges the body in itís ability to
eradicate infections.†

The main goal of exercise in a
patient with IDDM is to begin the management of blood glucose levels.† Blood glucose levels are decreased during
periods of exercise.2†† Glucose
is lowered by exercise due to increased permeability to glucose in peripheral
tissues.1 Glucose levels are the primary cause of cardiovascular and
neurological disorders in diabetics.†
With proper exercise, IDDM patients can begin to manage the amounts of
insulin required.† Exercise should
primarily be aerobic.† Resistance
exercises tend to increase blood pressure.†
Blood pressure increase is caused by increased intra-thoracic pressure
and muscular compression on blood vessels.†
This is non-beneficial to long-term diabetic patients who may have
decreased blood flow from atherosclerosis.†
This could result in possible cerebral vascular accidents or heart
attacks.

Exercise and itís Effects on Insulin

Exercise also plays an important
role in regulating insulin within the body.†
With exercise, insulin is not readily released from the pancreas due to
the lowered blood glucose levels.† This
self-regulation allows the body to not require insulin injections.† Unfortunately, exercise is easier said than
done.† Proper education to IDDM patients
will demonstrate that with healthy lifestyle choices, diabetes can me
managed.† The possibility may occur that
exercise and nutrition can become the patientís medication.†

The body is more sensitive to
insulin during exercise.† With the
decreased blood glucose levels, hypoglycemia may occur.† This condition can cause severe neurological
damage.† Decreased oxygenation to the
brain can cause death.2†† IDDM
patients must regulate their blood glucose levels at the beginning, middle, and
end of their exercise routines.† Glucose
levels below 70mg/dl will place a patient in a hypoglycemic state.† Un-educated patients may attempt insulin
injections and exercise in the same period that can lead to the above-mentioned
conditions.†

Insulin and itís Effects on Blood Glucose

††††††††††† Insulin has
many effects on the blood glucose levels throughout our body.† With increased levels of glucose in the
blood, insulin is secreted from the pancreas.†
Insulin is then released from the beta cells that are a type of islet
cells.3 †This release of
insulin causes an increased uptake of glucose in muscles, red blood cells, and
fat cells.3 †The increased
uptake manages the glucose levels in the body.†
If the glucose levels are steadily rising, a state called, hyperglycemia
may occur.† Hyperglycemia (glucose
levels > 140 mg/dl) occurs with the increased levels of glucose in the
bloodstream.2†

Exercise plays a crucial role when
dealing with glucose levels.† While
moderate exercise does decrease glucose levels in the body, rigorous exercise
can cause epinephrine to be released.2† This release of epinephrine can cause glucose levels to elevate
by transporting, ďstored glucose to blood glucose.Ē2† The release of epinephrine can put an IDDM
patient at risk to go from a controlled glucose level to a condition called
diabetic ketoacidosis.† This condition
can cause a diabetic coma if not managed correctly.† IDDM patients must be educated on the importance of various
levels of exercise, and the effects on glucose levels.††† †

Another primary role of insulin is
the processing of various nutritional elements such as proteins and
carbohydrates.† Insulin is involved in
amino acid transport.† Insulin is
disrupted in IDDM patients, and does not aide in protein synthesis.2† Without the correct processing of these
elements, our bodies begin to metabolize fats.†
The fats, after being broken down, increase the amount of glucose in our
body.† The increases in both glucose and
ketones may lead to diabetic ketoacidosis.†
Insulin affects not only the absorption of glucose, but also the
synthesis of various molecules.† This
leads to increased glucose production.†
This cycle is what IDDM patients need to comprehend in order to see the
benefits of exercise.†

IDDM patients must understand why
insulin injections need to occur at specific times.† Injecting insulin before exercise can cause glucose levels to
diminish, leading to hypoglycemia.†
Insulin must not be injected within one hour of performing exercise in
any extremity.2† This is
because insulin uptake is increased at the injection site.† This will cause a hypoglycemic affect to
occur leading to potential injury.†
Insulin can be regulated during pre and post exercise with proper nutrition
and blood glucose monitoring.† This
monitoring will keep a patient on top of their condition and able to properly
manage IDDM.

Guidelines for Diabetic Patients who Exercise

The most crucial guideline for IDDM
patients who exercise is the monitoring of blood glucose levels.† Before any exercise programs, a complete
medical evaluation should be performed to obtain baseline measurements.† IDDM patients must monitor their blood
glucose levels when performing exercises.†
Monitoring of the glucose levels should occur before, during, and after
exercises.† This monitoring allows for
the prevention of hypo and hyperglycemic conditions.† The following guidelines will be listed in outline form with a
rationale subset below:

1.Footwear & clothing:

a.Footwear should be donned during exercises that allows
comfortable and breath-ability to the patientís feet.† The importance of proper footwear is to protect patients from
incurring any injuries during exercise.†
With decreased sensation from neuropathy, the feet must maintain injury
free from bruising and blisters.† If
not, injuries will take longer to heal, thus causing the patient an extended
period away from their exercise program.†

b.Clothing needs to allow breath-ability and be appropriate for
the exercising environment.† Clothing
that retains heat and moisture is not appropriate for patients during
exercising.† An increase in core
temperature will decrease fluid retention and lead to a quicker onset of
dehydration.†††

2.Hydration:

a.Proper hydration should be within an armís reach so that
patient can have easy access to liquids.†
Hydration should not be with sodas or sugary beverages, which will alter
the blood/glucose levels.† Hydration
with water should occur before the onset of thirst.†††

3.Sugar snack:

a.A sugary snack can be given before exercise if blood glucose
levels are to low.2†† The
importance of the snack is to increase blood glucose levels in cases where
glucose levels are lower than 100 mg/dl.2†† These snacks should also be readily available and not in
vending machines.† The effects of
hypoglycemia are decreased with the intake of a sugary snack.† A carbohydrate snack should be eaten for
every 30 minute session of exercise for IDDM patients.2

4.Aerobic exercise versus resistance:

a.Aerobic exercise is the best form of exercise for Type I or II
diabetic patients.† This exercise does
not require quick bursts of energy, and resistance can be measured for
appropriateness.† Aerobic exercise also
allows the ability to increase cardiac muscle strength.† This improves the cardio and pulmonary
systems efficiency.

b.Resistance exercise may be performed by IDDM patients.† The guidelines are to closely monitor blood
pressure, heart rate, and respiratory rate.†
The importance of this monitoring is to protect long-term IDDM patients
from increasing blood pressure to an un-healthy measure.† Resistance exercises increase blood pressure
greatly.† Restricted blood flow in IDDM
patientís arteries can cause possible CVAís or heart attacks.† Resistance exercises are more appropriate
for diabetic patients who are young.†
This is due to the decreased length of time the disease has had on
affecting their vascular system.†

Exercise Program

Warm
up

Warm
up includes stretching with a slow increase in heart rate

Blood
glucose measurement

Exercise
period

Aerobic
exercise should include at least 20 minutes of exercise

i.Examples

1.Bike

2.Tread mill

3.Swimming

Blood
glucose measurement 10 minutes into program

Hydrate
continuously through session

Carbohydrate
snack if over 30 minutes of exercise.

Cool
Down

Slow
decrease in heart rate with stretching.

Blood
glucose measurement

i.Lowered glucose levels would be a reason to have a small meal
to increase blood glucose (Likely)

ii.Raised glucose levels will require an insulin injection to
decrease glucose in the bloodstream (Not as Likely)